Prioritizing

The Nursing Problem List

Using the Clinical Care Classification

- an evidence based Nursing terminology
in the patient’s plan of care

deborah.ariosto@vanderbilt.edu
Objectives
1. Describe components of the plan of care
2. State the value of using evidence based
care planning terms
3. Understand the CCC Nursing terminology
model within HED
4. Develop & Document a usable care plan
using CCC problem (Dx) list
VUMC
Multi-Disciplinary
Plan of Care
1 Pathway & Phase
 Sets timed objectives to
meet discharge goals based
on predominant medical or
surgical plan
2 Provider Plan
 Orders & planned
procedures
3 Multi-Disciplinary Plans
 Reflects provider orders
 Contributes specialty focus
4 Reflects patient goals
Pathway & Phase
Choose the pathway that most closely reflects the expected
patient progression. Usually the reason for admission.

Medical Pathway – Heart Failure

 Admission – Orders & interventions are aimed at achieving
stabilization ( improving pump action through diuresis, O2,
hemodynamic stability, . . .)
 Stabilization - achieving a controlled symptoms (fluid excess
control, med mgmt
 Discharge – Ready for self-care; or care by another caregiver.
Surgical Pathway - Knee Replacement
 Pre-op Pre; Post-op Stabilization; Discharge
Managing/preventing problems can help reduce length of stay
and improve the quality and cost bottom line
 Adverse patient effects
 hospital acquired conditions (infections, injuries)

 dissatisfaction (unhappy, lost wages) . . .

 Adverse VUMC effects

 lost revenue from under-reimbursed care days

 losing patients due to having no available beds . . .

Pathway Progression
Medical/Surgical Phases
I: Admission/Pre-Op

II: Stabilization/Post-op
Expected LOS
Problem: Infection/Fall
Phase

Extended LOS (under- III: Discharge

reimbursed)

Problem: Discharge Delay

- 2 4 6 8
Days
 Plans of Care
The clinical team
implements the medical Medical
Plan of Care
plan of care (orders)
and
contributes its own
specialty focus by
 Assessment
 Diagnosis Nursing Multi-D
Plan of Care Plan of Care
 Plan
 Intervention
 Outcome evaluation
 Assessment
Standards of Care (SOC*)
 Physical Assessment (standard met/not met)
 Past medical/surgical/functional Assessment
 Baseline vital signs . . .
 Screening scales: braden, fall, confusion, pain
Population based SOC
 Scales: Glascow coma, RASS, . . .
 More frequent and complex targeted assessment
 Mosby’s evidenced based guidelines (diabetes …)

* SOC – care administered without need for orders

Nursing diagnoses
= Problem List
Nursing diagnosis is "a clinical judgment about
individual, family, or community responses to
actual or potential health problems/life processes.

Nursing diagnoses provide the basis for selection of

nursing interventions to achieve outcomes for
which the nurse is accountable" (NANDA, 1992 p.
5). They describe clinical nursing practice in a
uniform manner.
 Evidence Base
The 182 Clinical Care Classification* (CCC) problems
(dx) were derived from 40,361 nursing diagnoses
and/or patient problems collected from the
research study patients for an entire episode of
care as requiring nursing services including the
actual outcome on discharge.

Standardizing our clinical terms helps us share

patient info across settings and disciplines; allows
us to empirically test our interventions and build
new evidence to advance the profession

*Developed by Virginia K. Saba, RN , PhD

CCC Framework
for the Nursing Plan of Care
21 Categories: Skin Integrity
182 Problems (Dx):
Oral Mucous Membranes Impairment
3 Expected Outcomes: Improve, Stabilize, Support decline
198 Interventions: Mouth Care
4 Actions: Assess, Care, Teach, Manage
3 Actual Outcome: Improved, Stabilized, Decline
supported
21 CCC Categories
Physiological Psych/Behavioral
 Cardiac  Cognitive
 Bowel/Gastric  Coping
 Life cycle (pregnancy)  Health Behavior
 Metabolic (glucose)  Role Relationship
 Physical Regulation (infection)  Self Care
 Respiratory  Self Concept
 Skin Integrity Functional
 Tissue Perfusion  Activity
 Urinary  Fluid Volume
 Nutrition
 Safety
 Medication  Sensory/Pain
 CCC Problem Coding*
59 major & 123 sub-categories

Category (R) Skin Integrity

 R46 Skin Integrity Alteration
Change in or modification of skin conditions
R46.1 Oral Mucous Membranes Impairment
R46.2 Skin Integrity Impairment
R46.3 Skin Integrity Impairment Risk
R46.4 Skin Incision
R46.5 Latex Allergy
 R47 Peripheral Alteration
Change in or modification of vascularization of the
extremities

*CCC codes map directly to multi-d concepts (SNOMED) supported by NLM

3 CCC Outcomes
Expected/Actual
1. Improve/Improved
 Condition will change and/or recover (fracture, pneumonia)
2. Stabilize/Stabilized
 Underlying Condition will not change but requires no further
nursing care to maintain (asthma, heart failure)
3. Support Decline/Decline Supported
 Condition will change and worsen (cancer, ESRD). Nursing
action supports decline.
Plan of Care
admission documentation
____________________Plan of Care Summary________________________
Pathway: CHF (chart once) Phase: Admission (update prn)

Nsg Summary: Pt admitted via ambulance in respiratory distress…

Plan Priorities: IV diuretics, fluid restrictions, I&O, reduce anxiety….
____________________Initial Problem______________________________
Priority Problem: Fluid Volume Excess
May be related to: CHF, fluid intake, hi Na diet
Exp Outcome: Stabilize
______________________q shift plan and outcomes__________________
Exp Outcome Detail: diurese .5L this shift
Exp Outcome Status: Not Met

Interventions: chart as usual

Activity Alteration
Change in or modification of energy used by the body
Activity Intolerance
Incapacity to carry out physiological or psychological daily
activities
Activity Intolerance Risk
Increased chance of an incapacity to carry out
physiological or psychological daily activities
Activity Indifference
Lack of interest or engagement in leisure activities Activity
Fatigue
Exhaustion that interferes with physical and mental
activities
Problems
Mobility Impairment
Diminished ability to perform independent movement
Sleep Pattern Alteration
Imbalance in the normal sleep/wake cycle
Sleep Deprived
Lack of the normal sleep / wake cycle
MuscSkeletal Alt
Change in or modification of the muscles, bones or
support structures Alt = Alteration
Physical Reg-Oth
Change in or modification of somatic control
Hyperreflexia
Life threatening inhibited sympathetic response to a
noxious stimuli in a person with a spinal cord injury at T7
or above
Hyperthermia
Abnormal high body temperature
Hypothermia
Abnormal low body temperature Physical
Thermoregulatory Impairment
Fluctuation of temperature between hypothermia and
Regulation
hyperthermia
Infection Risk
Increased change of contamination with disease-producing
germs
Infection
Contamination with disease-producing germs
IntrCranialFluid
Intracranial fluid volumes are compromised
Prioritizing Problems
Patients have many problems, what makes it a priority
problem?
When it
 Is the patient’s priority (pain, SOB, anxiety)
 Keeps the patient from moving to the next phase
(fluid volume excess)
 High probability for harm (infection risk, falls)
 Delays discharge

Note that Day & Night shift may have different

priorities (ambulation vs. sleep)
Choosing the best problem
descriptor
Choose the problem that most closely aligns with the
interventions that you will do for this phase.

My pt has Heart Failure – which problem do I pick?

If you are focusing on fluid mgmt (IV diuretics, I&O, lo

Na diet, fluid restriction) pick Fluid Volume Excess
If you are focusing on breathing treatments, choose
Respiratory Alteration

-------Neither are wrong – both may be selected -------

Maintaining a short - usable
Problem list
 Initiate problems thoughtfully & miserly – do not
replicate standards of care unless they are a priority
problem that you are actively monitoring or treating.
 Where possible, maintain the problems that have
been started by the previous nurse until there has
been significant progress towards goals or the
problem has been resolved. Do not change for a
slightly better descriptor.
 Not all problems need be addressed every shift – day
and night shift will have different priorities
 Use the HED significance flag !
 Plan Priorities reflects priorities for the next 12 hr.
Plan of Care Report
Available now in Standard HED format
(many pages – not well formatted)

Use as Backup
When paper is required
i.e. Transfer to another facility

August 2010:

A 1-2 page plan of care summary will be

available.

Goal – create a paper plan of care that

can be used in bedside report and given
to the patient and family.
Phase II - CCC Interventions

Example
Skin Integrity
Wound Care
Modifiers:
1. Assess wound care

2. Perform wound care

3. Teach wound care

4. Manage wound care (consult)

Future: HED documentation will be
mapped to the action types
RESPIRATORY CARE COMPONENT
(1) Assess
 Breath Sounds
 RUL
 RLL
 LUL
 LLL
 SOB etc.
(2) Perform
 Oxygen Therapy Care
 Breathing Exercises
 Chest PT
 Inhalation
 Ventilator Care
 Trach Care
(3) Manage/Refer/Notify
(4) Teach
Phase III – Reports & Views
1. Printed Plan of Care 2. Visualizing the
to share with the problem list through
patient and/or upload Dashboards
to MyHealth@V •Staff Nurse View

•Unit Manager View

•Exec/Admin Views
Graphical Display of
Priority Problems

Problems key:  Priority  Resolving  Resolved

Staff Nurse View cues to:

#1 CHF : Monitor cardiac, perfusion, fluid balance, resp

#2 Diabetic: Monitor glucose, diet, and skin
#3 CABG: Ambulate CABG & protect from falls
#4 Unknown: Diarrhea, fever, hypercapneic
Graphical Display of
Priority Problems

Charge Nurse View

Entire unit
Possible C-Diff outbreak
Graphical Display of
Priority Problems
Exec View
Entire Hospital
Highlights Discharge Concerns
Or
Opportunities
For targeted education &
surveillance
Spread the word
Look for opportunities to use the CCC terms
framework in your current work.
Plan of Care Exercise
Think about a recent Refer to Mosby’s
patient and review evidence based plans of
their pathway care if needed
•Fracture

•Burn

•Asthma

•COPD

Check of 3-5 high

priority problems from
the handout